89035A - Smith, Derrick

CAMA ❑ DREDGE & FILL N9 89035 r AA C D
Previous permit
t GENERAL PERMIT Date previous permit issued
New ❑ Modification ❑ Complete Reissue ❑ Partial Reissue
As authorized by the State of North Carolina, Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
I SA NCAC ❑ Rules attached. ❑ General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name
Address
City State ZIP
Phone#O
Email
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
Affected ❑CW DEW `X' PTA ❑ES ❑PTS Adj. Wtr. Body , -, k .(nat/man/unk)
AEC(s): ❑OEA ❑IHA nUW SPIMA ❑PWS Closest Mal. Wtr. Body c F.o-✓��^ I
ORW: yes/ ej PNA: yes/lip
Type of Project/ Activity f, I cLI, x `d
(Scale: N.I. %)
Shoreline Length _
Access Length _
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Total Platform area
Groin length/N
Bulkhead/ Riprap length
Avg distance offshore—
Breakwater/Sill
Max distance/ length_
Basin, channel
Cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other
SAV observed: yes <'
Moratorium: n/ayes no
Site Photos: yes no
Riparian Waiver Attached: r yes no
A building permit/zoning permit may be required by: L 1,10'r , Oo u r
Permit Conditions
❑ TAR/PAM/NEUSE/BUFFER (circle one)
1-1 See note on back regarding River Basin rules
See additional notes/conditions on back
I AM AWARE OF STATUTES, CRC RULESAND CONDITIONSTHAT APPLYTOTHIS PROIECTAND REVIEWED COMPLIANCE STATEMENT. (Please Initial)X
Agent or Applicant PRINTED Name
Signature **Please read compliance statement on back of permit**e\
('70 -"��. � I �,
Application Feels) Check #/Money Order
Permit Officer's PRINTED Name
�,1Mst
Signature
Issuing Date
''tZ;
Expiration Date

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONMAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner:
Address of Property: _
Mailing Address of Owner:
Owner's email: - fY' f'`
Agent's Name:
Agent's Email:
S r", t �
/(� 0 -3 %rn,l A)
x�OwnA/ cx) Cc'
er's Phone#:
Agent
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property Owner)
1 hereby certify that I own property adjacent to the above referenced property. The individual applyin or this
permit has described to me, as shown on the attached drawing, the development they are propos 9. A
description or drawing with dimensions must be provided with this letter.
I DO NOT have objections to this proposal. 100 have objections to this proposal.
If you have objections to what is being proposed, you must notify the N.C. Division of Coastal
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 401 S. Griffin St., Ste. 300, Elizabeth City, NC, 27909. DCM representatives can also be
contacted at [phone]. No response is considered the same as no objection if you have been
notified by Certified Mail.
WAIVER SECTION (Choose only one)
I understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or
groin must be set back a minimum distance of 15' from my area of riparian access unless waived by me
(this does not apply to bulkheads or riprap revetments). (If you wish to waive the setback, you must sign
the appropriate blank below.) rn r��\
I DO wish to waive some/all of the 15' setback Ua ;'\-
-OR-
t Signature ofAdjace iparian Pro e y Owner
I DO NOT wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO:
Mailing Address of ARPO: a3 7 COUP g� ou G OP,
ARPO's email: ARPO's Phone#: ASA - �-g3
Date: Ds D O *waiver is valid for up to one year from ARPO's Signature*
Revised August 2022

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner: l)e Pr-;C-y yM t t1/—
Address of Property: &, 0 3 Y() (Y-\itn/ 1 Yzn,I\
Mailing Address of Owner: 16 0 -S r n^�y { `� " ` e 'er M132
Owner's email: 'I) Ko V (141 fil) VAI L11O' Cowner's Phone#: G�3 y" 3 T) 7
Agent's Name:
Agent's Email:
Agent Phone#:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property Owner)
1 hereby certify that I own property adjacent to the above referenced property. The individual applying for this
permit has described to me, as shown on the attached drawing, the development they are proposing. A
description or drawing with dimensions must be provided with this letter.
r! I DO NOT have objections to this proposal. I DO have objections to this proposal.
If you have objections to what is being proposed, you must notify the N.C. Division of Coastal
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 401 S. Griffin St., Ste. 300, Elizabeth City, NC, 27909. DCM representatives can also be
contacted at [phone]. No response is considered the same as no objection if you have been
notified by Certified Mail.
WAIVER SECTION (Choose only one)
I understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or
groin must be set back a minimum distance of 15' from my area of riparian access unless waived by me
(this does not apply to bulkheads or riprap revetments). (If you wish to waive the setback, you must sign
the appropriate blank below.) /
I DO wish to waive some/all of the 15' setback
L-Signature of Adjacent Riparian Property Owner
-OR-
I DO NOT wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner: L16tee L- ej' L2c-Atf
Typed/Printed name of ARPO: � ti/
Mailing Address of ARPO: �� r`E �6X ! r"« L n
ARPO's email: ARPO's Phone#:
Date: c/ -LZ{_ Z T *waiver is valid for up to one year from ARPO's Signature*
Revised August 2022

2108
40ft
RECEIVED
MAY 0 2 2024
DCM-EC

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